This section contains an alphabetical list of fields and definitions in the application.
Fields are configured to be available in account search,workflow, and account list grid. These fields and their friendly names are set in the grid columns configuration by administrative users. This list may not have the full listing of fields as some fields are custom, however those listed are the most common.
| Term | Definition |
|---|---|
| 30 Day Readmit | Optional add-on to indicate if the patient has been readmitted within 30 days of the admit date. This field will populate with the previous account number and can be used for reporting. |
| Admit Reason | The reason registration typed in, not the admit reason set by the coder. |
| Assigned | The code was used for billing purposes. If you are looking for codes that are suggested or added by CDI for working/baseline purposes you would use the document code. Note: If designing workflow it is recommended this field is used for CDI, but for QA purposes its recommended thatâAssignedâ is used to ensure you are QA on what was billed vs what was suggested. |
| Baseline | The baseline data of the chart that would have been coded and billed without the intervention of CDI staff. This data is used to measure the impact that CDI has on a patientâs chart is then measured as the difference between the Baseline DRG and the Billed DRG (either the weights or the reimbursement). |
| Category | A category is a “Dolbey” created field used to further specify a patient type, if applicable. At some sites, category might equal patient type while others may have a category that is comprised of multiple fields to create that category. For example, if you would like to report on how many charts a coder completed for inpatient and then define them by LOS, you then have a category to define the difference between LOS patient types or service lines. |
| Document Code | Any code on a chart, manually entered or suggested. The code can be unassigned which means itâs not used for billing or assigned which is used for billing. Note: If designing workflow it is recommended this field is used for CDI, but for A purposes itâs recommended that âAssignedâ is used to ensure you are QA on what was billed vs what was suggested. |
| Document Type | The document(s) that are present on the patient account. The document types for searching and/workflow are required to have the interface name, not the friendly name. If you do not know the document names that are available to use, Dolbey can provide a table which provides this information. Send an email to results@dolbey.com requesting the document table names. |
| DRG Reconciled? | Reconciliation typically refers to a process that occurs when the working and final DRGâs do not match. Charts get flagged with a field called âIs DRG reconciledâ. If there is a check mark, then the chart has been reviewed and the chart has been reconciled either as an agree to disagree or agree and an adjustment is made to the working or final DRG once CDI and/or Coding does another review. |
| Final | Coded data added to the chart be billed out. |
| Next Review Date | Next review date is set either automatically by the system or manually by the CDI user if they choose to override the system automatic default date. The default date is whatever your management team has selected as a default interval for follow up reviews to occur. This may mean that the default is set for the next business day or two days later. This field is can be manually overridden by a CDS in the Code Summary viewer. Why would a CDS manually override this field? If you have reviewed the chart and know the patient is going to have surgery in a few days and there is no reason for a follow up review based on your sites policyâs. You may choose to augment the next review date for after the scheduled surgery. |
| Physician Query Open | The number of physician queries on the account that have not been closed. A physician response could have been received, but if it hasn’t been viewed by a user within CAC, the physician query is still considered “open”. |
| Physician Query Total | The number of queries on a chart, regardless of whether the queries are opened or closed. If a user was in an account that had an open physician query, and an external interface closed that query, the query total on the account is updated upon closing the account. |
| Reconciliation | A process that occurs when the working and final DRGâs do not match. Charts get flagged with a field called âIs DRG reconciledâ. If there is a check mark then the chart has been reviewed and the chart has been reconciled either as an agree to disagree or agree and an adjustment is made to the working or final DRG once CDI and/or Coding does another review. |
| Workgroup | A list of charts to be completed for coding, CDI or QA. Most charts flow into a Workgroup based upon automatic criteria, however admin user can route a chart to Workgroup (uncommon). |
| Working | The working information due to the intervention of the CDI staff. The CDI staff will update this information concurrently until the patient is discharged with additional data surrounding presenting problems or provisional diagnosis. |
| Field | Description |
|---|---|
| Abstract Patient Class | This is the abstraction Patient Class for the patient chart. |
| Account Number | This is the account number for the patient chart. |
| Account Status | This is the account status for the patient chart. |
| Active Matched Criteria Groups | This is the total number of active criteria groups on a patient chart. |
| Added to Images | This is how many total codes were added to an image document. |
| Added to Images | Total number of codes added to images |
| Admit Date | This is the admit date of the patient. Even though the field is named admit date time it only displays the date. |
| Admit Date w/ Time | Computed to display the patient’s admit date with the admit time |
| Admit Diagnosis Codes | This is the admit diagnosis code of the patient chart. |
| Admit Reason | This is the admit reason which comes from ADT. |
| Admit Source | This is the admit source of the patient chart. |
| Admit Type | This is the admit type on the patient chart. |
| Admitting Physician | Computed to display the first physician name with a role of Admitting. |
| Admitting Physician ID | Computed to display the first physician ID with a role of Admitting. |
| Age in Years | Computed to display the patient’s age in years. |
| Assigned CPT Code | This is used to search for a chart with an assigned CPT code. |
| Assigned Diagnosis Code | This is used to search for a chart with an assigned diagnosis code. |
| Assigned POA | |
| Assigned Procedure Codes | This is used to search for a chart with an assigned procedure (PCS) code. |
| Assigned Visit Reason Codes | This is used to search for a chart with an assigned visit reason code. |
| Attending Physician | Computed to display the first physician name with a role of Attending |
| Attending Physician ID | Computed to display the first physician ID with a role of Attending |
| AutoClose Date/Time | This is the date and time the patient chart was AutoClosed. |
| AutoClose Rejection Reason | This is the reason why the patient chart was rejected from AutoClose. |
| Baseline Working APRDRG | This is the Baseline APR-DRG. |
| Baseline Working DRG | This is the Baseline DRG. |
| Baseline Working DRG Weight | This is the Baseline DRG Weight. |
| Baseline Working Estimated Reimbursement | This is the Baseline DRG Estimated Reimbursement. |
| Bed | This is the last known patients bed. |
| Billing Countdown | The billing countdown will tell you how many days left to bill the payor. In Mapping Configuration," if you add or edit a mapping for ““Payor””"," you see a new ““Default Bill Days”” field in the header and a new ““Bill Days”” column for each Payor. These fields contain numbers zero or higher or blank to indicate the number of days to add to the discharge date (current date is there is no discharge date) to calculate what is basically a billing due date. The billing date is compared to the current date (or the last submitted date if the account is already submitted) to compute the ““Billing Countdown”” â the number of days left to submit an account. If an account has no payor", no matching payor mapping," or payor mapping with no ““bill days”” defined"," the ““default bill days”” is used (zero if ““default bill days”” is blank as well.) |
| Birth Weight (g) | This is the patients birth weight in grams. This can be provided either through the ADT interface or manually entered by a coder. |
| Building | This is the last known patients building which is usually equal to the nursing unit or location. |
| Calculated Date/Time | This field shows you the last time the encoder was last run, if it’s blank, the encoder needs to be run. This is so that in Account Search and workflow. This can help find an accounts that the user should have an APC, DRG or if you are reviewing to see if a coder clicked on the encode to run edits |
| Category | This is a Dolbey created patient type to assist with reporting because often a patient type field needed to be joined with a location, hospital service or other fields to alter reporting for productivity categories join those fields to create custom patient types for easy productivity and DNFC reporting. |
| CDI Physician Queries Agreed | This is the outcome of the query reporting by the CDI user closing the query. Agree commonly means that the physician provided the CDI with a valid diagnosis. |
| CDI Physician Queries Canceled | Not accessible in Query or Worksheet Designer. You can customize these by adding a mapping table using this key PhysicianQueryCancelReasons this will overwrite the default cancel options. |
| CDI Physician Queries Closed | This is the total number of physician queries closed issued by a CDI user. |
| CDI Physician Queries Disagreed | This is the outcome of the query reporting by the CDI user closing the query. Disagree commonly means that the physician provided the CDI with a different result than expected. |
| CDI Physician Queries No Opinion | This is the outcome of the query reporting by the CDI user closing the query. No Opinion commonly means that the physician provided the CDI with a clinically insignificant diagnosis. |
| CDI Physician Queries No Response | This is the total number of physician queries closed by a CDI user due to no response from the physician. |
| CDI Physician Queries Open | This is the total number of physician queries still open issued by a CDI user. |
| CDI Physician Queries Responded | This is the total number of physician queries responded to by Physician for issued by a CDI user. |
| CDI Physician Query Total | This is the total number of physician queries issued by a CDI user regardless of if the query is open or closed. If a user was in an account that had an open physician query, and an external interface closed that query, the query total on the account is updated upon closing the account. |
| CDI PSI Indicator | This is the PSIâs that were identified by a CDI user. The PSI indicator is identified by using the patient safety indicator technical specifications. This field requires the quality module. |
| CDI Quality Measure | This is a field used to identified if a CDI user identified PC-06. The PC- 06 indicator is identified by using the quality measures technical specifications. This field requires the quality module |
| Charge CPT Codes | Computed as a list of CPT codes assigned to Charges. Does not apply to Transactions. |
| Charge Revenue Codes | Computed as a list of Revenue Codes assigned to Charges. Does not apply to Transactions. |
| Coder Add Rate | Total number of codes that the coder manually added to text documents that the engine did not get correct compared to how many codes were ‘assigned’ |
| Coding Ready End Date/Time | This is a field used to identify the end date used for when a chart is completed by coding. |
| Coding Ready Start Date/Time | This is a field used to identify the start date used for when a chart is ready for coding. |
| Days to First Submit | This column will show the difference between the Discharge Date and the date the account was first submitted. This will also include the time along with the date, so the number will be shown as a decimal. |
| Denial Billed DRG | This is a field from the denial management viewer to display the billed DRG. |
| Denial Code Change Needed | This is a field from the denial management viewer to display if a code change is needed. |
| Denial Coder Id | This is a field from the denial management viewer to display the Coder Id that is to work the denial which could also be the coder of record. |
| Denial Codes in Question | This is a field from the denial management viewer to display the Code(s) in Question. |
| Denial Complete | This is a field from the denial management viewer to display if the denial is completed. |
| Denial DRG Change Needed | This is a field from the denial management viewer to display the if a DRG change is needed. |
| Denial Final Appeal Date | This is a field from the denial management viewer to display the Final Appeal Date. |
| Denial First Appeal Date | This is a field from the denial management viewer to display the First Appeal Date. |
| Denial First Appeal Sent Date | This is a field from the denial management viewer to display the First Appeal Sent Date. |
| Denial HIMS Received Date | This is a field from the denial management viewer to display the HIMS Received Date. |
| Denial Manager Assigned Date | This is a field from the denial management viewer to display the Manager Assigned Date. |
| Denial Notification Letter Date | This is a field from the denial management viewer to display the Notification Letter Date. |
| Denial Outcome | This is a field from the denial management viewer to display the Outcome of the Denial. |
| Denial Payer DRG | This is a field from the denial management viewer to display the Payer DRG. |
| Denial Reason | This is a field from the denial management viewer to display the reason of the Denial. |
| Denial Response Due Date | This is a field from the denial management viewer to display the Response Due Date. |
| Denial Reviewer ID | This is a field from the denial management viewer to display the Reviewer ID. |
| Denial Second Appeal Route | This is a field from the denial management viewer to display the Second Appeal Route. |
| Denial Second Appeal Sent Date | This is a field from the denial management viewer to display the Second Appeal Sent Date. |
| Denial Status | This is a field from the denial management viewer to display the status of the Denial. |
| Denial Third Appeal Route | This is a field from the denial management viewer to display the Third Appeal Route. |
| Denial Third Appeal Sent Date | This is a field from the denial management viewer to display the Third Appeal Sent Date. |
| Denial Type | This is a field from the denial management viewer to display the type of the Denial. |
| Discharge Date | This is the discharge date of the patient. |
| Discharge Date w/ Time | Computed to display the patient’s discharge date with discharge time |
| Discharge Date w/ Time | This is the discharge date with the time of the patient. |
| Discharge Disposition | This is the discharge disposition of the patient. |
| Discharged To | This is where the patient was discharged to. |
| Document Code | This is used to find any code suggested by the engine or added by a user assigned or unassigned. |
| Document Type | This is a field to identify a unique document name that is on a patient chart. |
| DRG Weight Difference | Computed to display the Final DRG Weight minus the Baseline Working DRG Weight |
| Effective Date | This is a field used to drive reoccurring patient charts. If the coder is coding multiple encounters within a single encounter in order to generate a bill for each they would code, set an effective date and save to generate an outbound message. If they need to code for another encounter date within the same they would change the date and re-save the account. |
| Engine DX Suggest Rate | How many DX codes the engine suggested compared to how many codes were ‘assigned’ |
| Engine PR Suggest Rate | How many procedure codes (PCS and/or CPT codes) the engine suggested compared to how many codes were ‘assigned’ |
| Exclude from Matched Criteria | This is a field to identify when we do not want a criteria group to display on the match criteria viewer. |
| Facility | This is the facility of the patient. |
| Final ALOS | This is the final ALOS on the patient chart. |
| Final APR-DRG | This is the final APR-DRG on the patient chart. |
| Final APR-DRG Description | This is the final APR-DRG Description on the patient chart. |
| Final APR-DRG GLOS | This is the final APR-DRG GMLOS on the patient chart. |
| Final APR-DRG Weight | This is the final APR-DRG weight on the patient chart. |
| Final CC Total | This is the final CC total on the patient chart. |
| Final DRG | This is the final DRG on the patient chart. |
| Final DRG Description | This is the final DRG Description on the patient chart. |
| Final DRG Weight | This is the final DRG weight on the patient chart. |
| Final Estimated Reimbursement | This is the final DRG Estimated Reimbursement on the patient chart. |
| Final GLOS | This is the final DRG GMLOS on the patient chart. |
| Final HAC Total | This is the final HAC total on the patient chart. |
| Final HCC Total | This is the final HCC total on the patient chart. |
| Final MCC Total | This is the final MCC total on the patient chart. |
| Final PPC Total | This is the final PPC total on the patient chart. |
| Final Risk of Mortality | This is the final APR-DRG ROM on the patient chart. |
| Final Severity of Illness | This is the final APR-DRG SOI on the patient chart. |
| Financial Class | This is the financial class of the patient. |
| First CDI Owner | This is the first CDI owner user Id on the patient chart. |
| First CDI Owner Date | This is the first CDI owner date on the patient chart. |
| First CDI Owner First Name | This is the first CDI owner first name on the patient chart. |
| First CDI Owner Last Name | This is the first CDI owner last name on the patient chart. |
| First CDI Saver | This is the first CDI saver user Id on the patient chart. |
| First CDI Saver Date | This is the first CDI saver date on the patient chart. |
| First CDI Saver First Name | This is the first CDI saver first name on the patient chart. |
| First CDI Saver Last Name | This is the first CDI saver last name on the patient chart. |
| First Coded Date | This is the first time the chart was submitted. |
| First Coder First Name | This is the first users first name that submitted the chart. |
| First Coder Last Name | This is the first users last name that submitted the chart. |
| First Coder User ID | This is the first users user Id that submitted the chart. |
| First CPT Code | This is the first sequenced CPT code coded by a coder. |
| First Diagnosis Code | This is the first sequenced Diagnosis code coded by a coder. |
| First Procedure Code | This is the first sequenced Procedure PCS code coded by a coder. |
| First Submitted Date | This is the first date the patient chart was submitted. |
| First Submitter First Name | This is the first users first name to submit the patient chart. |
| First Submitter Last Name | This is the first users last name to submit the patient chart. |
| First Submitter User ID | This is the first user id to submit the patient chart. |
| Floor | This is the last known patients floor location. |
| " | Has Late-Arriving Documents |
| Hospital Service | This field is used to identify the patients hospital service. |
| Is AutoClosed | This is a field that will tell if you if the chart was AutoClosed by the system. True means that it was. |
| Is DRG Reconciled | This is a field to tell if a patient chart was reconciled on submit. True means that either the Last known Working or alternative DRG matched the Final DRG. False means that either the patient charts Last known Working or alternative DRG listed did not match the Final DRG. This field is only applicable on inpatient charts. |
| Is Emergency Room Visit | This field identifies if the chart is an ER visit. |
| Is Inpatient | This field identifies if the chart is an inpatient chart. |
| Is Prior HCC Present | Computed as True if any prior account of the patient contains an HCC code. Field is defined in the site’s ADT script and performs a database lookup upon receipt of ADT for prior accounts. |
| Is Released by CDI | This field shows if the CDI user released the chart while in the reconciliation process on behalf of the coder from the submit state the coder originally submitted. |
| Is Resubmitted | Is Resubmitted is a term used to mean the chart was completed by coding and the chart had already had a submit action performed. If Is Resubmitted is True that means a coder has submitted this chart to billing a subsequent time. If Is Resubmit is equal to false then the chart has not been resubmitted and it was only submitted a single time. |
| Last CDI Owner Date | This is the last CDI Owner date they saved the account. An ownership can be claimed by selecting the owner button on the code summary viewer |
| Last CDI Owner First Name | This is the last CDI Owners first name. An ownership can be claimed by selecting the owner button on the code summary viewer. |
| Last CDI Owner Last Name | This is the last CDI Owners last name. An ownership can be claimed by selecting the owner button on the code summary viewer. |
| Last CDI Owner User ID | This is the last CDI Owners user id. An ownership can be claimed by selecting the owner button on the code summary viewer. |
| Last CDI Saver Date | This is the last CDI user that saved the accounts date. |
| Last CDI Saver First Name | This is the last CDI user that saved the accounts first name. |
| Last CDI Saver Last Name | This is the last CDI user that saved the accounts last name. |
| Last CDI Saver User ID | This is the last CDI user that saved the accounts user id. |
| Last Interface Update | This is the last date and time the interface received an update to the account. |
| Last Saved Date | This is the last coder user that saved the accounts date. |
| Last Saver First Name | This is the last coder user that saved the accounts first name. |
| Last Saver Last Name | This is the last coder user that saved the accounts last name. |
| Last Saver User ID | This is the last coder user that saved the accounts user id. |
| Last Submitted | Date This is the last coder user that submitted the accounts date. |
| Last Submitter First Name | This is the last coder user that submitted the accounts first name. |
| Last Submitter Last Name | This is the last coder user that submitted the accounts last name. |
| Last Submitter User ID | This is the last coder user that submitted the accounts user id. |
| Last Viewed Date/Time | This is the last viewerâs date they viewed the account without saving or submitting. |
| Last Viewer | This is the last viewerâs user id to view the account without saving or submitting. |
| Last Viewer First Name | This is the last viewerâs first name to view the account without saving or submitting. |
| Last Viewer Last Name | This is the last viewerâs last name to view the account without saving or submitting. |
| Late Document Count | This is the total documents that were late. Late is defined as post submit. |
| Late Document Type | This is the document types that are late arriving. |
| Length of Stay | Calculated; This is the current Length of Stay on the patientâs chart. This is Admit Date to Discharge Date and if Discharge Date is not present then itâs calculated to today’s date. This is different than the ALOS and the GMLOS that is calculated by the encoder. Often referred to as the LOS. |
| Location | This field can store the location but, commonly the location is stored within the building field not the location field. |
| Locked By | This is the current user that has the account locked which is defined by actively in use. |
| Locked Date/Time | This is the date and time the account became locked in use by the current user. |
| New Document Flag | Computed to true if any documents were imported onto account after the last time the account was saved. The user would see in the accounts grid a check mark to indicate True; Not accessible in Query or Worksheet Designer |
| Next Review Date | This field can be changed to a different date other than the default which is every day. This field is used by the CDI team to indicate the date that they want the chart routed back to the follow-up review worklist. This field can be found on the code summary page changing the calendar date field from the date displayed to a future date. This will tell the chart to not route back to the âFollow-up Reviewâ until the current calendar date matches the date you changed the next review date to. |
| Owner First Name | This is the current Owners first name. An ownership can be claimed by selecting the owner button on the code summary viewer. |
| Owner Last Name | This is the current Owners last name. An ownership can be claimed by selecting the owner button on the code summary viewer. |
| Owner Name | This is the current Owner date they saved the account. An ownership can be claimed by selecting the owner button on the code summary viewer. |
| Owner User ID | This is the current Owners user id. An ownership can be claimed by selecting the owner button on the code summary viewer. |
| Patient Birth Date | This is the patients birth date. |
| Patient Class | This is the patient class of the account. |
| Patient First Name | This is the patientâs first name. |
| Patient Gender | This is the patientâs gender. |
| Patient Last Name | This is the patientâs last name. |
| Patient Middle Name | This is the patientâs middle name. |
| Patient MRN | This is the patientsâ medical record number. |
| Patient Type | This is the patient type of the account. |
| Payor | This is the primary payor of the account. |
| Payor (Secondary) | This is the secondary payor of the account. |
| Pending Reason | An account can have zero or more pending reasons. Each pending reason can have additional properties Mappings Configuration and provides the client to control what pending reason are displayed for the role the end user has in addition to what other information should be recorded with a pending reason such as provider and date. Commonly, pending reasons can also trigger workflow and validation rules to ask the end user to take other actions such as adding a form to collect additional data such as CDI Questions or Quality Initiatives detail. |
| Pending Reason Physician ID | This is the physicians Id that is attached to the pending reason. |
| Pending Reason Physician Name | This is the physicians name that is attached to the pending reason. |
| Physician Coding Stage | This is the stage of the account for physician coding which is independent from the stage field which is known as the facility stage. |
| Physician Queries Agreed | This is the outcome of the query reporting by the physician coding user closing the query. Agree commonly means that the physician provided the CDI with a valid diagnosis. |
| Physician Queries Canceled | This is the outcome of the query reporting by the physician coding user closing the query as canceled. You can customize these by adding a mapping table using this key PhysicianQueryCancelReasons this will overwrite the default cancel options. |
| Physician Queries Closed | This is the total number of physician queries closed issued by a physician coding user |
| Physician Queries Disagreed | This is the outcome of the query reporting by the physician coding user closing the query. Disagree commonly means that the physician provided the physician coding with a different result than expected. |
| Physician Queries No Opinion | This is the outcome of the query reporting by the physician coding user closing the query. No Opinion commonly means that the physician provided the physician coding with a clinically insignificant diagnosis. |
| Physician Queries No Response | This is the total number of physician queries closed by a physician coding user due to no response from the physician. |
| Physician Queries Open | This is the total number of physician queries still open issued by a physician coding user. |
| Physician Query Responded | This is the total number of physician queries responded to by Physician for issued by a physician coding user. |
| Physician Query Total | This is the total number of physician queries issued by a physician coding user regardless of if the query is open or closed. If a user was in an account that had an open physician query, and an external interface closed that query, the query total on the account is updated upon closing the account. |
| Pre-Bill DRG Match | This field is shows true or false. True meaning that there was a pre- bill DRG match of the last know working and the final DRG. |
| Pre-Bill Final DRG | This is the final DRG pre-bill. |
| Pre-Bill Final DRG Description | This is the final DRG Description pre-bill. |
| Pre-Bill Final DRG Weight | This is the final DRG Weight pre-bill. |
| Pre-Bill Working DRG | This is the working DRG pre-bill. |
| Pre-Bill Working DRG Description | This is the working DRG Description pre-bill. |
| Pre-Bill Working DRG Weight | This is the working DRG Weight pre-bill. |
| Pre-Visit Account Number | Not accessible in Query or Worksheet Designer |
| Primary Grouper | This is the primary grouper of the account. |
| Principal CPT Code | This is the principal CPT code on the account. |
| Principal CPT Modifier | This is the principal CPT code modifier(s). The user can add up to 4 modifiers unless they are using the Solventum CRS encoder, then they will be able to add up to 5 modifiers. |
| Principal CPT Physician | This is the principal CPT code abstracted physician. |
| Principal Diagnosis Code | This is the principal diagnosis code on the account. |
| Principal Procedure Code | This is the principal procedure (PCS) code on the account. |
| Principal Procedure Physician | This is the principal procedure (PCS) code abstracted physician. |
| PSI Indicator | This is the PSIâs that were identified by a coder user. The PSI indicator is identified by using the patient safety indicator technical specifications. This field requires the quality module. |
| Public Note | This is the public note. |
| Public Note Date/Time | This is the date and time that the public note was created. |
| Public Note User ID | This is the users id that created the public note. |
| Quality Measure | This is a field used to identified if a coder user identified PC-06. The PC-06 indicator is identified by using the quality measures technical specifications. This field requires the quality module. |
| Random Inclusion Factor | Computed to display a random number between 1 and 100; Not accessible in Query or Worksheet Designer |
| Redundant Code Count | Total number of codes that the coder added manually but the engine suggested the code already |
| Room | This is the last known room of the patient. |
| Secondary Grouper | This is the secondary grouper of the account. |
| Service Type | This is the service type of the account. |
| Stage | The stage of the patient tells you if the patient chart is unbilled, billed (submitted), In Review (QA). |
| Submit Account for Post- QA | This is used in workflow to define when a chart qualifies for a QA Review worklist if it should be prebill or post bill review. True indicates it will be a post bill account and False is Prebill. |
| Time Spent By CDI | This is the total time spent in an account for a user with a CDI role. |
| Time Spent By Coding | This is the total time spent in an account and any subsequent time after the first time it was saved or submitted for a user with a Coder role |
| Time Spent By First Coder | This is the total time spent in an account for the first timefor a user with a Coder role. |
| Total Charges | This is the total charges on the patient chart. Commonly, this information is sent on the ADT interface. |
| Total Documents | Computed to display the total number of documents on the account. |
| Total DX Codes | Total number of diagnosis codes submitted |
| Total Procedure Codes | Total number of procedure codes (PCS and/or CPT codes) submitted |
| Transfer From | This is where the patient was transferred from. |
| Transfer To | This is where the patient was transferred to. |
| Validation Rule Count at Submit | This tells you if there were any active validation rules at Submit. |
| Workflow Trigger Date | Not accessible in Query or Worksheet Designer |
| Workgroup | This field identifies what current default workgroup the patient chart is currently within. |
| Workgroup Assigned By | This is used to indicate that user manually assigned the chart to another userâs âYouâ worklist. |
| Workgroup Assigned Date | This field identifies the date that the patient chart qualified for the current workgroup. |
| Workgroup Category | This field identifies what current workgroup(s) category the patient chart is currently within. |
| Workgroup Submitted | This is used in QA workflow to identify that a chart should not requalify for a QA workgroup if it was previously submitted from it to prevent chart looping. |
| Workgroup Type | In Workflow Management," each workgroup now has a new ““WorkGroup Type”” field. This field is optional", but sites can designate a type for each workgroup. The purpose of doing so is for current and future reporting. For this feature," setting a workgroup to a type besides ““Coding”” will exclude the account’s time assigned to it in the ““Coding Chart Status Report””. |
| Working Admit Diagnosis Code | This is the working admit diagnosis code. |
| Working ALOS | This is the working ALOS. |
| Working APRDRG | This is the working APR-DRG. |
| Working APRDRG Description | This is the working APR-DRG Description. |
| Working APRDRG GLOS | This is the working APR-DRG GMLOS. |
| Working CC Total | This is the working CC total count. |
| Working CPT Codes | This is used to identify working CPT Codes. |
| Working Diagnosis Codes | This is used to identify working diagnosis Codes. |
| Working DRG | This is the working DRG. |
| Working DRG Description | This is the working DRG Description. |
| Working DRG Weight | This is the working DRG Weight. |
| Working Estimated Reimbursement | This is the working DRG Estimated Reimbursement. |
| Working GLOS | This is the working DRG GMLOS. |
| Working HAC Total | This is the working HAC total count. |
| Working HCC Total | This is the working HCC total count. |
| Working MCC Total | This is the working MCC total count. |
| Working PPC Total | This is the working PPC total count. |
| Working Principal CPT Code | This is used to identify working principal CPT Codes. |
| Working Principal Diagnosis Code | This is used to identify working principal diagnosis Codes. |
| Working Principal Procedure Code | This is used to identify working principal procedure (PCS) Codes. |
| Working Procedure Codes | This is used to identify working procedure (PCS) Codes. |
| Working Risk of Mortality | This is the working APR-DRG ROM. |
| Working Severity of Illness | This is the working APR-DRG SOI. |
| Working Visit Reason Codes | This is used to identify working Visit Reason Codes. |
| Field | Formula |
|---|---|
| Abstracting Accuracy Rate | (Procedure (PCS/CPT) Date Changes + Procedure (PCS/CPT) Provider Changes + Discharge Disposition Changes + Consulting Provider Changes/Abstracting Pre-Audit) - 100%. |
| Abstracting Error Rate | Procedure (PCS/CPT) Date Changes + Procedure (PCS/CPT) Provider Changes + Discharge Disposition Changes + Consulting Provider Changes/Abstracting Pre-Audit. |
| Abstracting Errors | Procedure (PCS/CPT) Date Changes + Procedure (PCS/CPT) Provider Changes + Discharge Disposition Changes + Consulting Provider Changes. |
| Abstracting Pre-Audit | (Total Procedure and CPT Codes x 2) + 1 for Discharge Disposition + 1 for Consulting Providers if Present). Procedure and CPT Codes are multiplied by two since there are to abstraction opportunities which is date of service and preforming provider. |
| CPT Accuracy Rate | (CPT Codes Added + CPT Codes Edited + CPT Codes Unassigned + Principal CPT Changed/CPT Codes Pre-Audit) â 100% |
| CPT Error Rate | Procedure Codes Added + Procedure Codes Edited + Procedure Codes Unassigned + Principal CPT Changed/CPT Codes Pre-Audit |
| CPT Errors | CPT Codes Added + CPT Codes Edited + CPT Codes Unassigned + Principal CPT Changed |
| Diagnosis Accuracy Rate | (Diagnosis Codes Added + Diagnosis Codes Edited + Diagnosis Codes Unassigned + POA Changes + Principal Dx Changed/ Diagnosis Codes Pre-Audit) â 100%. This line will be highlighted in blue so the data stands out. |
| Diagnosis Error Rate | Diagnosis Codes Added + Diagnosis Codes Edited + Diagnosis Codes Unassigned + POA Changes + Principal Dx Changed/ Diagnosis Codes Pre-Audit |
| Diagnosis Errors | Diagnosis Codes Added + Diagnosis Codes Edited + Diagnosis Codes Unassigned + POA Changes + Principal Dx Changed |
| Procedure Accuracy Rate | (Procedure Codes Added + Procedure Codes Edited + Procedure Codes Unassigned + Principal PCS Changed/ Procedure Codes Pre-Audit) â 100% |
| Procedure Error Rate | Procedure Codes Added + Procedure Codes Edited + Procedure Codes Unassigned + Principal PCS Changed/ Procedure Codes Pre-Audit |
| Procedure Errors | Procedure Codes Added + Procedure Codes Edited + Procedure Codes Unassigned + Principal PCS Changed |
| Total Accuracy Rate | This is the total overall accuracy as a percentage the formula is: Total Errors = (Diagnosis Errors + Visit Reason Errors + Procedure Errors + CPT Errors + Abstracting Errors/Total Pre-Audit) â 100%. |
| Total Error Rate | This is the total overall error rate as a percentage the formula is: Total Errors = Diagnosis Errors + Visit Reason Errors + Procedure Errors + CPT Errors + Abstracting Errors/Total Pre-Audit. |
| Total Errors | This is the total overall errors that appear in the above boxes the formula is as followed: Total Errors = Diagnosis Errors + Visit Reason Errors + Procedure Errors + CPT Errors + Abstracting Errors. |
| Visit Reason Accuracy Rate | (Visit Reasons Added + Visit Reasons Codes Edited + Visit Reasons Codes Unassigned/Visit Reasons Pre-Audit) â 100%. This line will be highlighted in blue so the data stands out. This will only display on an outpatient chart |
| Visit Reason Error Rate | Visit Reasons Added + Visit Reasons Codes Edited + Visit Reasons Codes Unassigned/Visit Reasons Pre-Audit. This will only display on an outpatient chart. |
| Visit Reason Errors | Visit Reasons Added + Visit Reasons Codes Edited + Visit Reasons Codes Unassigned. This will only display on an outpatient chart. |
| Field | Description |
|---|---|
| APR-DRG Change? | This is a yes or no field. If the APR-DRG was changed from the previous DRG assignment. N/A is available in the event the auditor wants to list it as not applicable to the audit. Note if the Billing DRG and the APR-DRG as the same there could be duplication of changes reported on this field and the MS-DRG field which is the Billing DRG. |
| APR-DRG ROM Change? | This is a yes or no field. If the APR-DRG changed resulted in an ROM (Risk of Mortality) change. N/A is available in the event the auditor wants to list it as not applicable to the audit. |
| APR-DRG SOI Change? | This is a yes or no field. If the APR-DRG changed resulted in an SOI (Severity of Illness) change. N/A is available in the event the auditor wants to list it as not applicable to the audit. |
| MS-DRG Change? | This is a yes or no field. If the billing DRG was changed from the previous DRG assignment. N/A is available in the event the auditor wants to list it as not applicable to the audit. Note if the Billing DRG and the APR-DRG as the same there could be duplication of changes reported on this field and the APR-DRG Change field. |
| Reimbursement Change Amount | This is a field that indicates if the billing DRG change resulted in a change the amount will be displayed. |
| Reimbursement Change? | This is a field that indicates if the billing DRG change resulted in a increase, decrease or no reimbursement change. N/A is available in the event the auditor wants to list it as not applicable to the audit. |
If the auditor disagrees with any of the auto-calculated fields below, they can choose to override the field by entering in the value that makes sense per the audit. The system will provide an audit trail to show what the value was changed from and to for transparency along with the user that made the change and the date/time the change was performed.
| Field | Description |
|---|---|
| Abstracting Accuracy Rate | This is the total abstracting accuracy as a percentage |
| Abstracting Error Rate | This is the total abstracting error rate as a percentage |
| Abstracting Pre-Audit | The total is the number of abstracting components there were at the time the audit is started. |
| Audit Closed by First Name | This is the auditor/coder first name who closed the audit. |
| Audit Closed by Last Name | This is the auditor/coder last name who closed the audit. |
| Audit Closed by User Id  | This is the auditor/coder user Id who closed the audit. |
| Audit Closed Date | This is the date the audit was closed. |
| Audit Coder Agree | This is if the coder agreed with the audit or if they decided to rebuttal. |
| Audit Coder of Record First Name | This is the coders first name that last submitted the chart prior to audit start. |
| Audit Coder of Record Last Name | This is the coders last name that last submitted the chart prior to audit start. |
| Audit Coder of Record User Id | This is the coders user Id that last submitted the chart prior to audit start. |
| Audit Opened by First Name | This is the auditor first name whom opened the audit. |
| Audit Opened by Last Name | This is the auditor’s last name who opened the audit. |
| Audit Opened by User Id  | This is the auditor user Id who opened the audit.  |
| Audit Opened Date | This is the date the audit was opened by the auditor. |
| Audit Rebuttal Comment | This is the rebuttal comment from the coder. |
| Audit Rebutted by First Name | This is the coders first name who rebutted the audit. |
| Audit Rebutted by Last Name | This is the coders last name who rebutted the audit. |
| Audit Rebutted by User Id | This is the coders user Id who rebutted the audit. |
| Audit Rebutted Date | This is the date the audit was first rebutted. |
| Audit Response to Rebuttal | This is the response from the auditor for the rebuttal from the coder. |
| Audit Returned Date | This is the date that the audit was returned to the coder. |
| Audit Sub-Types  | This is the audit sub-type. |
| Audit Training Recommendations | This is the training recommendations if applicable that the auditor recommends for the coder. |
| Audit Training Topics | These are the training topics if applicable that the auditor recommends for the coder. |
| Audit Type | This is the audit type. |
| CC Added | This is the count of the total of added codes that has a classification of CC (complication or comorbidity) by the auditor on secondary codes once the auditor selects the update codes button. The added action is defined by right clicking on a code from the unassigned code tree  right clicking on a code to validate from a document or adding a code that did not exist previously. These are not counted in the total error rate to prevent duplication of errors. This will only display on an inpatient chart. |
| CC Removed | This is the count of the total of removed codes that had a classification of CC (complication or comorbidity) by the auditor on secondary codes once the auditor selects the update codes button. The unassign action is defined by right clicking on a code from the assigned code tree and selecting one of the unassign diagnosis code   unassign as secondary  unassign as admit or by selecting edit diagnosis code and deleting the code. These are not counted in the total error rate to prevent duplication of errors. This will only display on an inpatient chart. |
| CPT Accuracy Rate | This is the total codes that appear in the above boxes the formula is as followed: CPT Error Rate = (CPT Codes Added + CPT Codes Edited + CPT Codes Unassigned + Principal CPT Changed/CPT Codes Pre-Audit) ââŹâ 100%   |
| CPT Codes Added  | This is the count of the total of added or assign actions by the auditor for principal and secondary codes once the auditor selects the update codes button. The assign action is defined by right clicking on a code from the unassigned code tree and selecting assign as principal or secondary   right clicking on a code to validate from a document or adding a code that did not exist previously. |
| CPT Codes Edited | This is the count of the total of edit actions by the auditor for principal and secondary codes once the auditor selects the update codes button. An edit is defined as a simple change to the same code category such as the last digit of a code however if the auditor replaced the full code this is still counted as an edit rather than an unassign and an add. The editing action is defined by right clicking on a code from the assigned code tree and selecting edit CPT code with a replacement procedure code. |
| CPT Codes Post-Audit | The total is the number of CPT codes including principal and secondary at the time the auditor selects the Update Codes button |
| CPT Codes Pre-Audit | The total is the number of CPT codes including principal and secondary at the time the audit is started. |
| CPT Codes Unassigned | This is the count of the total of deleted or unassign actions by the auditor for principal and secondary codes once the auditor selects the update codes button. The unassign action is defined by right clicking on a code from the assigned code tree and selecting one of the unassign principal code  unassign as secondary  unassign all episodes or by selecting edit procedure code and deleting the code. |
| CPT Error Rate | This is the total codes that appear in the above boxes the formula is as followed: CPT Error Rate = Procedure Codes Added + Procedure Codes Edited + Procedure Codes Unassigned + Principal CPT Changed/CPT Codes Pre-Audit |
| CPT Errors | This is the total codes that appear in the above boxes the formula is as followed: CPT Errors = CPT Codes Added + CPT Codes Edited + CPT Codes Unassigned + Principal CPT Changed. |
| Diagnosis Codes Added | This is the count of the total of added or assign actions by the auditor for admit and secondary codes once the auditor selects the update codes button. The assign action is defined by right clicking on a code from the unassigned code tree and selecting assign as admit or secondary   right clicking on a code to validate from a document or adding a code that did not exist previously. This total does not include Reason for Visit as they are calculated separately. |
| Diagnosis Codes Edited | This is the count of the total of edit actions by the auditor for admit and secondary codes once the auditor selects the update codes button. An edit is defined as a simple change to the same code category such as the last digit of a code however if the auditor replaced the full code this is still counted as an edit rather than an unassign and an add. The editing action is defined by right clicking on a code from the assigned code tree and selecting edit diagnosis code with a replacement diagnosis code. This total does not include Reason for Visit as they are calculated separately. |
| Diagnosis Codes Post- Audit | The total is the number of diagnosis codes including principal  admit and secondary at the time the auditor selects the Update Codes button. This total does not include Reason for Visit as they are calculated separately. |
| Diagnosis Codes Pre-Audit | The total is the number of diagnosis codes including principal   admit and secondary at the time the audit is started. This total does not include Reason for Visit as they are calculated separately. |
| Diagnosis Codes Unassigned | This is the count of the total of deleted or unassign actions by the auditor for admit and secondary codes once the auditor selects the update codes button. The unassign action is defined by right clicking on a code from the assigned code tree and selecting one of the unassign diagnosis code   unassign as secondary  unassign as admit or by selecting edit diagnosis code and deleting the code. This total does not include Reason for Visit as they are calculated separately. |
| Discharge Disposition Changed? | This is a true or false field. If the Discharge Disposition was changed from the previous Disposition assignment the field will result in true which is counted as one error and if it was not changed it will result in false which is not counted as an error. N/A is available in the event the auditor wants to list it as not applicable to the audit. |
| HAC(s) Added | This is the count of the total of added codes that has a classification of HAC (Hospital Acquired Condition) by the auditor on secondary codes once the auditor selects the update codes button. The added action is defined by right clicking on a code from the unassigned code tree   right clicking on a code to validate from a document or adding a code that did not exist previously. These are not counted in the total error rate to prevent duplication of errors. This will only display on an inpatient chart. |
| HAC(s) Removed | This is the count of the total of removed codes that had a classification of HAC (Hospital Acquired Condition) by the auditor on secondary codes once the auditor selects the update codes button. The unassign action is defined by right clicking on a code from the assigned code tree and selecting one of the unassign diagnosis code  unassign as secondary  unassign as admit or by selecting edit diagnosis code and deleting the code. These are not counted in the total error rate to prevent duplication of errors. This will only display on an inpatient chart. |
| MCC Added | This is the count of the total of added codes that has a classification of MCC (major complication or comorbidity) by the auditor on secondary codes once the auditor selects the update codes button. The added action is defined by right clicking on a code from the unassigned code tree  right clicking on a code to validate from a document or adding a code that did not exist previously. These are not counted in the total error rate to prevent duplication of errors. This will only display on an inpatient chart. |
| MCC Removed | This is the count of the total of removed codes that had a classification of MCC (major complication or comorbidity) by the auditor on secondary codes once the auditor selects the update codes button. The unassign action is defined by right clicking on a code from the assigned code tree and selecting one of the unassign diagnosis code   unassign as secondary  unassign as admit or by selecting edit diagnosis code and deleting the code. These are not counted in the total error rate to prevent duplication of errors. This will only display on an inpatient chart. |
| POA Changes | This is the count of the total of POA changes only on unchanged codes (Edited or Added) to prevent double counting errors once the auditor selects the update codes button. If a code was edited   assigned/added or unassigned/deleted it will not be counted within this total. This will only display on an inpatient chart. |
| Principal CPT Changed | This is a true or false field. If the principal CPT was changed from the previous code assignment the field will result in true which is counted as one error and if it was not changed it will result in false which is not counted as an error. N/A is available in the event the auditor wants to list it as not applicable to the audit. |
| Principal Dx Changed | This is a true or false field. If the principal diagnosis was changed from the previous code assignment the field will result in true which is counted as one error and if it was not changed it will result in false which is not counted as an error. N/A is available in the event the auditor wants to list it as not applicable to the audit. |
| Principal PCS Changed | This is a true or false field. If the principal PCS was changed from the previous code assignment the field will result in true which is counted as one error and if it was not changed it will result in false which is not counted as an error. N/A is available in the event the auditor wants to list it as not applicable to the audit. |
| Procedure Codes Added | This is the count of the total of added or assign actions by the auditor for principal and secondary codes once the auditor selects the update codes button. The assign action is defined by right clicking on a code from the unassigned code tree and selecting assign as principal or secondary, right clicking on a code to validate from a document or adding a code that did not exist previously. |
| Procedure Codes Edited | This is the count of the total of edit actions by the auditor for principal and secondary codes once the auditor selects the update codes button. An edit is defined as a simple change to the same code category such as the last digit of a code however if the auditor replaced the full code this is still counted as an edit rather than an unassign and an add. The editing action is defined by right clicking on a code from the assigned code tree and selecting edit procedure code with a replacement procedure code. |
| Procedure Codes Post-Audit | The total is the number of procedure codes including principal and secondary at the time the auditor selects the Update Codes button. |
| Procedure Codes Pre-Audit | The total is the number of procedure codes including principal and secondary at the time the audit is started. |
| Procedure Codes Unassigned | This is the count of the total of deleted or unassign actions by the auditor for principal and secondary codes once the auditor selects the update codes button. The unassign action is defined by right clicking on a code from the assigned code tree and selecting one of the unassign principal code, unassign as secondary, unassign all episodes or by selecting edit procedure code and deleting the code. |
| Total Modifiers Added | This is the count of the total of added modifiers on a CPT by the auditor where the code previously existed. If the code was already counted within the CPT Codes Added section to prevent duplication of errors. The added action is defined by right clicking on a code from the assigned code tree and selecting to edit to add a modifier. |
| Total Modifiers Removed | This is the count of the total of removed modifiers on a CPT by the auditor where the code previously existed. If the code was already counted within the CPT Codes Added section to prevent duplication of errors. The removed action is defined by right clicking on a code from the assigned code tree and selecting to edit to remove an existing modifier. |
| Visit Reasons Added | This is the count of the total of added or assign actions by the auditor for reason for visit codes once the auditor selects the update codes button. The assign action is defined by right clicking on a code from the unassigned code tree and selecting assign as visit reason  right clicking on a code to validate from a document or adding a code that did not exist previously. This will only display on an outpatient chart. |
| Visit Reasons Edited | This is the count of the total of edit actions by the auditor for reason for visit codes once the auditor selects the update codes button. An edit is defined as a simple change to the same code category such as the last digit of a code however if the auditor replaced the full code this is still counted as an edit rather than an unassign and an add. The editing action is defined by right clicking on a code from the assigned code tree and selecting edit diagnosis code with a replacement diagnosis code. This will only display on an outpatient chart. |
| Visit Reasons Post-Audit | The total is the number of reason for visit diagnosis codes at the time the auditor selects the Update Codes button. This will only display on an outpatient chart. |
| Visit Reasons Pre-Audit | The total is the number of reason for visit diagnosis codes at the time the audit is started. This will only display on an outpatient chart. |
| Visit Reasons Unassigned | This is the count of the total of deleted or unassign actions by the auditor for reason for visit codes once the auditor selects the update codes button. The unassign action is defined by right clicking on a code from the assigned code tree and selecting one of the unassign diagnosis code  unassign as visit reason or by selecting edit diagnosis code and deleting the code. This will only display on an outpatient chart |
| Field | Description |
|---|---|
| E/M Critical Care CPT Code | This is the Critical Care CPT Code that was generated based upon time entered from within the ER E/M Worksheet. |
| E/M Critical Care Duration | This is the Critical Care time duration that was entered in by the coder either manually or using the time helper based upon time entered from within the ER E/M Worksheet. |
| E/M ER Date | This is the ER date the user entered into the ER E/M Worksheet. |
| E/M ER Physician First Name | This is the ER Physician First Name the user entered into the ER E/M Worksheet. |
| E/M ER Physician ID | This is the ER Physician ID the user tied to the physician entered on the ER E/M Worksheet. |
| E/M ER Physician Last Name | This is the ER Physician Last Name the user entered into the ER E/M Worksheet. |
| E/M Is CC Criteria Met | This is the radio button outcome from the CC Criteria Met that the user manually entered from within the ER E/M Worksheet. |
| E/M Is CC Time Determined | This is the radio button outcome from the CC Time Determined that the user manually entered from within the ER E/M Worksheet. |
| E/M Level CPT Code | This is the E/M Level CPT Code that was generated based upon the matrix selections entered from within the ER E/M Worksheet. This pertains to level 1-5 as critical care is documented in the E/M Critical Care CPT Code. |
| E/M Level Number | This is the E/M Level that was generated based upon the matrix selections entered from within the ER E/M Worksheet. This pertains to level 1-5 as critical care is documented separately. |
| E/M No Charge CPT Code | This is the No Charge CPT Code that was generated based the selection entered from within the ER E/M Worksheet. |
| E/M No Charge Description | This is the No Charge Description that was generated based the selection entered from within the ER E/M Worksheet. |
| E/M Trauma | This is the Trauma selection that was entered from within the ER E/M Worksheet. |